In response to the demand for improving the capture of chronic illness diagnoses for reimbursements, the Center for Medicare and Medicaid Services (CMS) mandated the development of the Hierarchical Categorical Condition (HCC) code system and implemented it in the year 2004. The incorporation of the HCC codes has helped drive CMS payments to Medicare Advantage (MA) members. Significant attention has been devoted towards improving savings for hospitals and health plans, under the Patient Protection and Affordable Care Act – with special focus on prevention. Mismanagement of chronic illnesses leads to high expenditure levels, driving up costs and reducing profits. HCC coding helps providers get properly reimbursed for the services that they provide by ensuring that chronic illnesses are properly captured within medical records.
However, HCC is dependent on two major steps for accurate reimbursement:
- Patient encounters must be accurately documented by physicians to ensure that the same is properly reviewed by medical coders.
- HCC coding specialized medical coders must review the complete medical record of the patient to identify all HCC codes in the record.
HCC codes are used to establish capitation payments for health plans for the following year by CMS, and thus it is critical that codes are captured year round. If a submission is missed over outside of a year period, it can cause a delay in payments to the health plan. Since reimbursements have become more dependent upon effective capture of diagnoses, HCC coding has become increasingly important.
Getting reimbursement through Medicare Advantage, and for work with patients with related insurance providers, can be tricky as these health plans are reimbursed on the basis of the patients’ chronic conditions. If you make mistakes during diagnosis, or submit a diagnosis with errors, you run the risk of not being in compliance. This will also happen if you deliver a diagnosis which results in a new hierarchical condition category (HCC). Any compliance risk is also a risk that you won’t be paid for your work.
What are the most common HCC coding mistakes? Knowing them and then ensuring that you take steps to negate these errors will lead to error free submissions and hence, complete and timely reimbursements. This is the list of the ten most common errors made:
- Legible signatures and signatures with credentials were not entered on the record.
- EHRs (electronic health records) were not authenticated. Double-check for an electronic signature.
- The most appropriate ICD-9-CM code wasn’t used with the narrative description of the diagnosis or symptoms within the medical chart.
- The diagnosis codes turned in for billing did not match the description written into the record. Even minor differences, such as the difference between 311 Depressive Disorder and 296.20 Major Depressive Affective Disorder, can nullify your billing.
- No evidence of monitoring, evaluation, assessment/address, and treatment was included in the documentation.
- Chronic medical conditions were not recorded as chronic.
- Records did not include the highest level of specificity regarding symptoms and conditions.
- Annual records were not kept for chronic conditions.
- There was a failure to report the necessary manifestation code.
- Old codes were used rather than current codes.
The best way to overcome the challenges of incorrect submissions is to work with a company that provides you with certified coders, who ensure that coding, billing, compliance and other related tasks are error free and timely. This will allow you to spend more time doing what you do best – treat patients.
Errors in coding lead to denied claims and ultimately loss of revenue. Take a look at the free ICD-10 Coding Guide, which covers A-Z coding tips and will help in providing insight into ICD-10 coding parameters.
- Olson, C. (2013, March 20). Top 10 Medicare Risk Adjustment Coding Errors. Retrieved October 31, 2016, from www.aapc.com: https://www.aapc.com/blog/23877-top-10-medicare-risk-adjustment-coding-errors/
- Risk Adjustment. (2016). Retrieved October 31, 2016, from www.cms.gov: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html
- Ten Common HCC Coding Mistakes. (2016). Retrieved October 31, 2016, from www.hcccoders.com: http://www.hcccoders.com/ten-common-hcc-coding-mistakes/